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Wednesday, September 3, 2014

When Safety Makes Us Unsafe

It’s sort of one of those provocative questions – is there
such a thing as too much safety? In a
sense, this is the wrong question (primarily because “safety” is such a
subjective term). Basically though, is there a point at which if we add more
safety interventions we not only get diminishing returns, but we also make
things worse?

If we all thought hard enough I’m sure we can think of
examples where safety interventions led to unintended consequences in the form
of hazards. For example, anyone who’s worn a hard hat for a length of time has
likely experienced the increase in
the number of times you hit your head on things. Or those who wear extra
chemical protective clothing who are more exposed to heat stress issues as a
result. It’s not that these protections are or are not required necessarily.
However, we can see that, in the wrong circumstances using these protections
will not make you any safer, and you could argue it would make you less safe (e.g. if you were wearing a
full chemical moon suit, such as in the picture above, while you’re reading
this blog would that make you more or less safe?).

This concept can be applied to organizational interventions
as well. Take example many well meaning organizations that, in an effort to
motivate employees, use incentives for employees when they go a certain period
with having an injury. The idea makes sense on the surface as a reasonable
safety intervention. However, even the US Occupational Safety and Health
Administration has come out against such programs because of the unintended
consequence of motivating employees to not report injuries (and even motivating
some safety professionals to play the “numbers game” and hide injuries).

These are easy and tangible examples of a broader concept
that can even be more dangerous in other circumstances. We say more dangerous
because when the downsides are not obvious that makes them harder to spot,
which can also give us a false sense of security. We start to believe that our
interventions are making us safe, when they may be doing nothing, or, worse,
they may even be making things worse.

Take, for example, a strategy that a lot of companies adopt
to show that their top management cares about safety – the idea that if you
report an incident it automatically has to get reported up the corporate chain,
everyone hears about it, and the CEO (or someone similar) gets involved. Sounds
like a great way to show that the organization means business when it comes to
safety, right? Recently we were working in an organization with exactly that
policy. When asked how many incidents get reported the answer was “not many.”
When we were with line employees we asked if there had been any incidents that
should have been reported – yes. So an intervention designed to increase
accountability and visibility for safety actually made the organization dumber,
because they were missing opportunities to learn.

The problem is not that these people are not well-meaning.
The problem is that we need to understand that whenever we implement a change,
even a safety change, we are implementing it into a complex system that is
already in operation. Systems don’t have “pause” buttons. Any change we make
will interact with other parts of the system, in either predictable or
unpredictable ways. That means there will almost always be unintended
consequences when we implement a change and those unintended consequences could
actually make us less safe.

There are plenty of other examples of this as well, some
which are very complex:

The organization that decided any risk reduction set a
precedent and could never be reversed, leading to reluctance in implementing
future risk reduction measures (which may have contributed to a fatal incident).

Defense in depth strategies, which can work great in some
contexts, but, according to Perrow, may work to make our systems more complicated
or complex, leading to less predictability and more risk.

Risk compensation, or risk homeostasis theory, which says
that any intervention we implement may lead to increases in risk taking
behavior, as people learn to rely on the intervention to protect them.

Now this doesn’t mean that all of these interventions are
bad and we should do nothing. The real problem, as we said above, is a failure
to understand complex systems and how any intervention, even well meaning ones,
can have unintended consequences. So, our job in the safety profession, if we
really want to do good is to find ways to facilitate safety while minimizing or
accounting for those consequences. Here’s some recommendations to get you
started:

Take the time to understand systems, particularly complex
systems. We have a couple blogs on the issue (here and here). Plus
you should read these two books by Meadows and Dekker.

Research shows that getting diverse opinions involved in
decision-making increases decision quality. So stop making decisions on your
own. Get other people involved in the decision-making process, particularly
people who have a different background and perspective as you.

Never make a decision about an operation that doesn’t
include a healthy amount (read: a whole lot) of input from the people who will
actually be doing the job. (In fact, our real recommendation is that you
shouldn’t even be making the decision. You should be the one providing input,
with the people doing the job making the decision.)

Always follow-up on interventions to identify if they are
having their intended effect and any unintended effects. Too often we just
implement something and make, at best, rudimentary efforts to see if it’s
working. And it’s very important that you look for examples of the intervention
not working, not just examples of it working. It’s too easy to see what you
want to believe, unfortunately. (But, of course, if it wasn’t then we wouldn’t
be talking about this subject to begin with.)